Laserfiche WebLink
WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-6232(209)468-3420 <br /> NON-REFUNDABLE PERMIT www.sigov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> 1 <br /> JOB ADDRESS VL �+ CRV21P Q <br /> CA <br /> D <br /> CROSS STREET vA�+ :.1 e ' APN 3v 0 Oa PARCEL SIZE ,T,.o USE APPLICATION <br /> `�• v� ` (• <br /> OWNER NAME PHONE <br /> pl <br /> OWNERADDRESSRN�C_710O CITY/STATEIZIP '-^' <br /> CONTRACTORGW�ij�ePHONE C4 , <br /> r r(I <br /> CONTRACTOR ADORE55 CITYI$TATE/ZIP Y l.(i <br /> SUBCONTRACTOR/CONSULTANT ' `�`- PHONE <br /> SUBCONTRACTOR/CONSULTANT ADDRESS Cr1v///S,TTAT _ <br /> LICENSE C-57 C$1 [7 D-09 ❑Other NUMBER 1� IRATION DATE <br /> BILLING PARTY: ❑OWNER ❑CONTRACTOR ❑ SUBCONTRACTORICONSULTANT <br /> DOMESTIC WELL PLINIO.O General ineral/Coliform Bacteria(4391)❑Dibromochloropropane(4392)❑Arsenic(4393) <br /> INTENDED USE mestcJPrivate _ Irrigabon/Agncultural [I Industrial ❑Water Quality Monitoring �]Soil Sampling/Characterization <br /> Public Water System Y <br /> If different from Owner Water Sy /PA <br /> stem Name Contact Name or Phone Number A/�' <br /> TYPE OF WORK New Well i Replacement Well Well Alteration/Modification Other �Gy' <br /> ❑Monitoring WellVeinWallis) <br /> ❑Out-Of-Service Well Out-Off-Service Well Renewal ❑Cross-Connection Repair <br /> ❑New Pum r__Pump Replacement Pump Repair ❑Raise Well Casing <br /> WELL COSJ 20,2�/ <br /> Drilling Method ud Rotary ' i-Air Air Rotary Auger'I���Cable Tool ❑Push Point ❑ Other S jQ '� <br /> Proposed Well Depth `%V it Excavation�in diameter .l Open Bottom /�',+�-Gravel Pack/Gravel Size in dia e V/RQU/N CSU <br /> Condu asing n diameter / Con((0�IyctQJf C�as�ing Depth ft ]h DEF ENTA�� <br /> Well Casing Diameter -yn /Gauge/ASTM Sc, <br /> ❑Steel 1(Qlaslic ❑Stainless Steel Other ARTME <br /> Grout Seal Dept Neat Cement(94/b bag/S10gal water) Sand Cement sack mixf7 gal water <br /> XBentonite(20%solids) Other <br /> Grout Placement Method dumped ❑Free F I Other Retardant I Accelerator(name) <br /> PEDESTAL Installed By i..Driller XPump Contractor Other <br /> ❑Concrete Pedestal❑ mensions:Width ft Length It Thick in Christy Box Stove Pipe <br /> PUMP ❑SubmemibleC Turbine : Other HP Pump Set ft Standing Water Level ft <br /> 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. 1 ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS CO N TION LAWS. <br /> MIN U CE NOTICE REQUIRED FOR Y, T(O�NNS^-PLEASE CALL(209)3 0�7' <br /> SIGNED / TITLE t l/1/ DATE <br /> /DEPARTMENT U E ONLY t��] <br /> Application Accepted By ` Date 3 Jay J Area E� Employee IDN 1/A <br /> Grout Inspection By t Date -LI)1t1 SPECIAL Well Permit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring I e ion/B�y Date Constructed Well De th h <br /> COMMENTS p�1 4ifDY�Nt YVS. w itH CrrSlf'ilP LiedN h�MS7E;fc � ;,/z/I Gep�h yjouibr <br /> be— 3Xa .feiet—e'Q_ <br /> PE SC Received Checld# Amount ate PermW Invoice Well ID# <br /> Codes Info Remitted Service R asst# <br /> 46 190 ao rl <br /> EHD 43-06 6/112019 WELL(PUMP PERMIT <br />